Rheumatoid Arthritis

Educational Solutions for Workforce Development

Pharmacy

Carole Callaghan

Principal Pharmacist

NHS Lothian

Pharmacy Aim

To update pharmacists on the current

management of rheumatoid arthritis and

explore ways to implement

pharmaceutical care for this patient group

as part of normal working practice.

Pharmacy Objectives

• Describe the common signs and symptoms associated with

rheumatoid arthritis.

• Define the current therapeutic management for both the

alleviation of symptoms and for modifying disease progression

in rheumatoid arthritis.

• Identify pharmaceutical care issues and appropriate

management solutions when responding to symptoms in patient

scenarios.

• Explore how to implement the principles of a pharmaceutical

care needs assessment tool in practice.

Pharmacy Rheumatoid Arthritis

A chronic systemic inflammatory disease,

characterised by potentially deforming

symmetrical polyarthritis and extra-

articular features.

Pharmacy Epidemiology

• prevalence approx. 1% in UK

• 3:1 ratio of females:males affected

• peak onset 40 and 50 years of age

• genetic, environmental and infective

factors involved in disease development

Pharmacy Pathogenesis

• cause remains unknown

• toxic substances found in synovium

• destruction of joints

• immunological disturbances identified

• RA is an autoimmune disease

Pharmacy Pathology

• disease of the synovium

• inflammation due to infiltration of

lymphocytes, macrophages etc

• proliferation of cells results in ”pannus”

formation

Pharmacy Pathology

Pharmacy Symptoms

• joint pain (usually worse on waking)

• morning stiffness (can vary in duration)

• general symptoms e.g. fatigue, malaise,

bone ‘ache’

Pharmacy Signs

• swelling

• tenderness

• reduced range of movement

• deformities (if untreated over long-term)

• extra-articular features e.g. nodules,

anaemia of chronic disease, pleural

effusion

Pharmacy Signs

Pharmacy Joint involvement

• hands/wrists

• elbows/shoulders

• cervical spine

• knees

• ankles/feet

• unpredictable pattern

Pharmacy Investigation

• Imaging e.g. x-ray, ultrasound, MRI

• FBC and ESR

• Other tests e.g RhF, anti-CCP

(antibodies)

Pharmacy Management (1st stage)

• lifestyle – maintain where possible

• multidisciplinary e.g.

– physiotherapy

– occupational therapy

– podiatry

Pharmacy Management (2nd stage)

• relief of symptoms

Pharmacy NSAIDs

• more effective than simple analgesics

• variation in response

• balance efficacy

• and toxicity

Pharmacy NSAID toxicity

• related to dose and duration of therapy

– GI

– renal and cardiovascular

– elderly more at risk

Pharmacy GI toxicity

• well documented in literature

• identifiable risk factors e.g. age, previous history, other medication (steroids, warfarin), alcohol

• improved use secondary to identifying those at risk and using gastroprotection

Pharmacy NSAID summary

• use lowest dose compatible with

symptom relief

• use gastroprotection in “at risk” patient

• reduce and, if possible, withdraw when

good response from DMARD

Pharmacy COX-2 Inhibitors

• selectively block COX-2 isoenzyme

• provide pain relief (as efficacious as NSAIDs)

• less GI bleeding than NSAIDs (less significant

GI symptoms remain e.g. dyspepsia)

• CV risk

Pharmacy Management (3rd stage)

• long-term suppressive drug therapy with

disease modifying anti-rheumatic drugs

(DMARDs)

Pharmacy Early DMARD

• stabilise joint function as early as

possible = better outcome

• greater awareness of NSAID toxicity

• DMARDs slow disease progression

Pharmacy DMARDs

• efficacy .vs. toxicity

– methotrexate and sulfasalazine have

the best efficacy:toxicity ratio in meta-

analyses

• Increased use of combination therapy –

TICORA, COBRA, BeST.

– better than sequential monotherapy

Pharmacy DMARDs (cont)

• DAS28 (Disease Activity Score)

-swollen joints

-tender joints

-patient’s general health score

• Monitoring

-urinalysis

Pharmacy Systemic corticosteroids

• not recommended for routine use

• if necessary, use lowest dose, shortest

• monitor due to side effect profile

Pharmacy Intra-articular corticosteroids

• “target” joint i.e. one or two large joints affected, can avoid systemic steroid

• maximum number per joint/time – but no evidence for this theory

• evidence lacking for this practice,

but patients report benefit

Pharmacy Biologic Pathways

Pharmacy Nomenclature

-ximab Chimeric antibody

-zumab Humanised antibody

-umab Human antibody

-cept Fusion protein

Pharmacy Immunogenecity

Pharmacy

Eligibility Criteria for Biologic Therapy

DAS28 >5.1

At least 2 previous DMARDs

Adequate response at 3 months

3-monthly monitoring

Pharmacy TNF a

Four agents currently licensed in UK and

SMC approved:

infliximab (human antichimeric antibody)

etanercept (fusion protein)

adalimumab (fully humanised monocloncal antibody)

golimumab (human monoclonal antibody)

Pharmacy Effects of Blocking TNFa

Immunology

RF, T cell function restored

Inflammation

Cytokine production in joints (IL1, IL6, TNF)

Angiogenesis

levels of angiogenesis

Joint destruction

damage to bone and cartilage

Haematology

platelets, fibrinogen, restoration of Hb

Pharmacy Infection

Do not initiate in presence of serious

active infection or in patients at high risk

of infection

Discontinue in presence of serious

infection

Pharmacy Tuberculosis

Screen for TB

Active TB needs to adequately treated

Prophylactic anti-TB therapy for potential latent

disease

Monitor during/after biologic; treat if required

Pharmacy Vaccination

Data limited

Influenza and pnuemococcal

recommended

Live vaccines not recommended

Pharmacy Malignancy

No increased risk of solid tumours or

lymphoproliferative disease

Investigate/stop therapy

Caution in pre-malignant conditions

Preventative skin care/ongoing surveillance

Pharmacy Rituximab

With MTX only

Inadequate response or intolerant of other

DMARDs, including at least one anti-TNF

By specialists in accordance with criteria

Pharmacy Abatacept

Selective T cell co-stimulation modulator –

blocks the co-stimulatory signal required for full

T cell activation

Not recommended by SMC and reserved for

refractory disease. However, this advise superseded by

NICE MTA 195 and can now be used in those who have failed

DMARDs or anti-TNF

With MTX only and available as IV infusion or SC injection

Pharmacy Tocilizumab

Recommended by SMC for combination

or monotherapy

Can be used as first-line biologic in those who are

intolerant of MTX or where continued MTX not suitable

ADRs - monitoring important e.g. liver enzymes,

neutropenia, lipids

Pharmacy Summary

• RA = inflammatory & destructive

• symptomatic relief

• early disease modification

Rheumatoid Arthritis - NHS Education for Scotland...rheumatoid arthritis. • Define the current...

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